All professions are conspiracies against the laity.
George Bernard Shaw1
There are certain phrases, particularly when used by company presidents, CEOs, senior administrators, and department heads, that over the years, have taken on a somewhat loaded meaning. One of the first to go sour was the “pursuit of excellence.” Over the past few decades, this phrase has developed from its face-value meaning to one with implications related to productivity, living within a budget, and flag waving to indicate the superiority of whatever is to be achieved by a particular institution. Other examples abound.
“Quality” has had to be modified by words such as “assurance” and “improvement,” and is now used to differentiate between those who follow the precepts of evidence-based practice and those who do not (the bad guys) because their knowledge and experience have shown them that a large portion of our databases is adequate. “Quality of life” is another hackneyed phrase, even yet quantified into units that now cloak the arrogant assumption that the personal value of a life can be exactly measured. The semantics of leaders who promote “professionalism” leave us to ponder what “professionalism” is all about and what is happening to it.
A profession is classically defined as a calling or vocation, especially one that involves some branch of advanced learning or science. The essence of professionalism is both having a unique or special knowledge and the self-imposed obligation to serve the community. Until recently, this has been an unwritten contract, and for these reasons, society holds the professional in higher esteem than it does a technician, blue-collar worker, or businessman, people who traditionally are interested in the benefits of their employment rather than the occupation itself. Professionals are expected to show a degree of special attainment, altruism, and self-sacrifice in their dealings with the rest of the community and in return receive privileges both in the workplace and at large. Professionals have been allowed to determine the makeup of their profession and maintain a degree of exclusivity.
Most societies demand some degree of regulation and licensing, require codes of professional conduct, and expect professions to practice self-discipline in the management of their affairs and members. There is also a tacit understanding that professions are given status for the benefit of society, both in the present from the skills they already possess and in the future from advances in knowledge and understanding.
Society’s View of the Professions
In the past, especially in liberal times, the professions of the church, medicine, and the law were frequently the focus of popular humor, as a means of ridiculing the miscreant behavior of professionals. The overfed and worldly prelate has been a character in many popular plays. The 18th-century satirist Jonathan Swift (more famous as the author of Gulliver’s Travels) remarked on the fickleness of the medical profession that when the Plague arrived, the doctors were the first to leave town. His contemporary, Thomas Walker,2 the playwright and composer of operas, wrote on the greed of lawyers in a love song from one of his lesser known operas, The Quaker’s Opera:
When I stop loving thee
The lawyer’ll forgo his fee.
Another part of the bargain is that society holds the professional to a higher standard of ethics, honesty, and morality than the rest. In their public declarations, professional politicians claim that it is unfair for their indiscretions to be held against them, claiming that what they did was what most everyone else does!
Leaders must be more accountable for their behavior because the stakes are higher. A wayward private life made public for political advantage stopped the higher echelons of the US government for nearly a year from doing anything productive during Bill Clinton’s presidency. Professional leaders need to realize that the higher they rise, the more exposed they become. The role-model aspect of professionalism can give way to the unmerciful social eye given to eminence. It is unfortunate that to maintain the advantages of professionalism, it is much safer to look good than to set a contrarian example, since highly placed professionals’ misbehavior makes news in the press.
How does the status of professionalism prevail in healthcare today? It would be hard to suggest that it is faring well. The pressures and restrictions produced by diminishing resources, an aging population that has overindulged in a lifetime of unhealthy habits, and successful outcome measures based on financial restraint have diminished the aspiration to serve. In turn, the public sees professionals as wreckers of the social contract whenever a professional body does not keep its own house in order, and abrogates the responsibility for admonishing or expelling members who are impaired or who have demonstrated unprofessional conduct or incompetence. This behavior has lead to a belief “that collegiality, a valuable part of professionalism, has been used to protect professional colleagues.”3 The fallout from this and other breeches of trust that arise from regional variation in outcomes and the failure of teaching institutions to be sensitive to the population they serve has led to demands for evidence-based practice, guidelines, recertification, revalidation, and peer review.3
Accountability and the Health Professions
The loyalties of professionals are, in large part, a creation of the society in which they work. The traditional loyalty in healthcare has been first and foremost to the interests of an individual patient, and hopefully this will remain a prime objective. Many new responsibilities are being added to healthcare practitioners’ ever-expanding load of obligations. Medical and nursing leadership are given responsibility for length of stay. We are all accountable for costs and documentation to insurers and corporations as well as governmental oversight agencies, which has led to the witticism that “accountability” should be written “accounting ability”! Nonprofessional behavior now runs the gamut from a missing signature on a chart to outright fraud, as well as the improprieties surrounding patient care. One of the more taxing burdens is the husbanding of resources.
Critical care is a limited resource, so that those who direct critical care units have to triage, prioritize, and manage institutional requirements. In dispensing the social justice of trying to benefit patients most in need of a bed in an intensive care unit, the intensive care unit medical or nursing director may be faced with all the arguments of a “balloon debate” and have to decide the winner. If the director does the best possible with what is available, then the precepts of professionalism are satisfied. If the director has to give way to the internal politics of an institution, he or she will have been compromised and, unfortunately, given administrative praise for cooperation! This is a demoralizing situation for all unit staff. When professionals are left feeling that they are no longer valued for their professionalism, altruism will wither away and society is the loser.
Challenges to Professional Values
Another erosion of professional values is occurring with the unionization of healthcare professionals. In many states, this representation by trade unions has become the norm for nursing staff. House staffs now are becoming unionized more frequently, with more senior physicians being enrolled whether they approve or not. Trade unions rightfully should look to the working conditions and employment of members, but tend to destroy the ideals of professionalism because they are not patient centered. Unions generally look askance at altruistic behavior and at the professional who wishes to go the extra mile for a patient. Furthermore, union rules may not allow for the recognition or rewarding of those who show outstanding professionalism.
Staffing and resources are in short supply, and there is an increasing population of elderly patients suffering from the effects of an unhealthy life style. The healthcare workplace is becoming more stressful, and working conditions have deteriorated. If we are to be patient centered, making the best we can with what we have is a more certain professional approach than trying to get a better deal through a trade union. There is an incompatibility crisis emerging with the adoption of staffing ratios by unions and regulators when there is a worldwide shortfall in the number of nurses needed to maintain the ratios.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is another example of how a perceived breach of professionalism has given rise to regulations that are codifying the age-old fiduciary relationship between professional and patient that surrounds confidentiality. This legislation has spawned an industry that helps institutions comply with HIPAA regulations. Patients should have a right to privacy, as it is not only an ethical requirement, but it also allows for an open discussion with the professional staff. Such openness in communication can only be to the patient’s advantage. (Some patients are surprised to find that their confidentiality can be legally shared with various governmental departments and organizations paying for care.) HIPAA regulations are reasonable, but they derive from a lack of public trust in professional confidentiality.
Since 1999, an international consortium has been meeting to raise the concept of professionalism in medicine with a reaffirmation of the profession’s civic commitment. The Medical Professionalism Project is a group consisting of representatives from the American College of Physicians-American Society of Internal Medicine, the American Board of Internal Medicine, and the European Federation of Internal Medicine. The rationale for this collaborative effort was:
. . .because medical professionalism is universally endangered. The unionization of residents and practicing physicians, conflicts of interest precipitated by managed care and for-profit medicine, and the paradoxical role of the pharmaceutical industry in patient care and medical education are but a few issues. . . .4
So far, the result has been the “Charter on Medical Professionalism,”5,6 which clearly defines medicine’s contract with society and the relationship of the public trust to professional integrity. The fundamental principles of the primacy of patients’ welfare and autonomy and of social justice lead to specific professional responsibilities; for example, a commitment to competence, honesty with patients, and confidentiality. This is a courageous and superbly well-crafted document dealing with what medicine should stand for in our high-tech, problematical world. The charter should be adopted by physicians and provide a basis for all health-care professionals’ codes of conduct.
The professionalism of critical care nurses, like physicians, is suffering the same destructive assaults from a healthcare system that is increasingly profit driven. Collaborative efforts across the disciplines to maintain professional values are urgently needed. We look to the readers of this journal, as well as to our respective professional associations, to lead the way. Autonomy and altruism cannot be subjugated to profit motive, and the strategies used by our professions to deal with often untenable work situations must still reflect our commitment as professionals to patients. Our patients deserve nothing less.
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